Exploring the cost-effectiveness of a one-off screen for dementia (for people aged 75 years in England and Wales)

Health economic analysis of the integrated cognitive assessment tool to aid dementia diagnosis in the United Kingdom

Objectives

The aim of this study was to develop a comprehensive economic evaluation of the integrated cognitive assessment (ICA) tool compared with standard cognitive tests when used for dementia screening in primary care and for initial patient triage in memory clinics.

Methods

ICA was compared with standard of care comprising a mixture of cognitive assessment tools over a lifetime horizon and employing the UK health and social care perspective. The model combined a decision tree to capture the initial outcomes of the cognitive testing with a Markov structure that estimated long-term outcomes of people with dementia. Quality of life outcomes were quantified using quality-adjusted life years (QALYs), and the economic benefits were assessed using net monetary benefit (NMB). Both costs and QALYs were discounted at 3.5% per annum and cost-effectiveness was assessed using a threshold of £20,000 per QALY gained.

Results

ICA dominated standard cognitive assessment tools in both the primary care and memory clinic settings. Introduction of the ICA tool was estimated to result in a lifetime cost saving of approximately £123 and £226 per person in primary care and memory clinics, respectively. QALY gains associated with early diagnosis were modest (0.0016 in primary care and 0.0027 in memory clinic). The net monetary benefit (NMB) of ICA introduction was estimated at £154 in primary care and £281 in the memory clinic settings.

Conclusion

Introduction of ICA as a tool to screen primary care patients for dementia and perform initial triage in memory clinics could be cost saving to the UK public health and social care payer.

Screening for preclinical Alzheimer's disease: Deriving optimal policies using a partially observable Markov model

Alzheimer's Disease (AD) is believed to be the most common type of dementia. Even though screening for AD has been discussed widely, there is no screening program implemented as part of a policy in any country. Current medical research motivates focusing on the preclinical stages of the disease in a modeling initiative. We develop a partially observable Markov decision process model to determine optimal screening programs. The model contains disease free and preclinical AD partially observable states and the screening decision is taken while an individual is in one of those states. An observable diagnosed preclinical AD state is integrated along with observable mild cognitive impairment, AD and death states. Transition probabilities among states are estimated using data from Knight Alzheimer's Disease Research Center (KADRC) and relevant literature. With an objective of maximizing expected total quality-adjusted life years (QALYs), the output of the model is an optimal screening program that specifies at what points in time an individual over 50 years of age with a given risk of AD will be directed to undergo screening. The screening test used to diagnose preclinical AD has a positive disutility, is imperfect and its sensitivity and specificity are estimated using the KADRC data set. We study the impact of a potential intervention with a parameterized effectiveness and disutility on model outcomes for three different risk profiles (low, medium and high). When intervention effectiveness and disutility are at their best, the optimal screening policy is to screen every year between ages 50 and 95, with an overall QALY gain of 0.94, 1.9 and 2.9 for low, medium and high risk profiles, respectively. As intervention effectiveness diminishes and/or its disutility increases, the optimal policy changes to sporadic screening and then to never screening. Under several scenarios, some screening within the time horizon is optimal from a QALY perspective. Moreover, an in-depth analysis of costs reveals that implementing these policies are either cost-saving or cost-effective.

Economic evaluation of the screening for Alzheimer’s disease in China

Background

We evaluated the cost-effectiveness of the screening in mainland China for Alzheimer’s disease (AD) patients aged over 60.

Methods

Individuals in mainland China, received an initial screening by questionnaire on mental state, and those with scores deemed suspicious for AD were referred to diagnostic tests. A 9-state Markov model was developed to simulate the disease progression of a cohort of 100,000 subjects aging from 60 to 80. In addition, several scenarios were analyzed to assess the robustness under different screening frequency, starting age, the duration of drug effects, and the health status of subjects.

Results

The ICER of AD screening was 26413.77 USD per QALY [quality-adjusted life-year (QALY)] compared with no screening. The number of deaths and severe AD cases who did not receive treatment averted by screening accounted for 0.076 and 0.006% of the total population, respectively, and the net monetary benefit was 128.29 USD per capita. Under the thresholds of one and three times the gross domestic product per capita, the probability of screening being cost-effective was approximately 18 and 77%, respectively. The ICER decreased to 18132.96USD per QALY when the drug effect was prolonged, and increased when the frequency of screening was increased, the starting age was postponed, and patients suffering from comorbidities were more. However, the number of severe AD cases and deaths declined when the screening frequency increased.

Conclusion

Screening for AD in individuals over 60 can reduce the numbers of severe AD cases and deaths and may be cost-effective, depending on factors such as screening frequency, starting age of screening, and duration of drug effects. Additionally, mild cognitive impairment (MCI) is an important stage at which the burden of progression to AD may be reduced and the cost-effectiveness of screening may be improved.

Economic impacts of introducing diagnostics for mild cognitive impairment Alzheimer's disease patients

INTRODUCTION

Disease-modifying treatments for Alzheimer's disease (AD) are likely to be offered only to patients with molecular evidence for Alzheimer pathology and expanded to patients with prodromal AD. We calculated the potential future costs of expanding the number of positron emission tomography (PET) and cerebrospinal fluid (CSF) tests in the United Kingdom.

METHODS

We conducted a focused literature review and consulted experts to obtain information on the current use of PET and CSF to diagnose prodromal AD, staffing and equipment requirements for these tests, and associated costs.

RESULTS

We estimate annual costs of 100,000 extra amyloid PET scans and 100,000 extra CSF tests at £113 million and £48 million, respectively; these costs are likely to be higher in the first year.

DISCUSSION

The budgetary impacts are not insignificant but are small in comparison to the likely market price of any disease-modifying treatments or to the probable costs of missed or inaccurate diagnosis.

Decision modelling of non-pharmacological interventions for individuals with dementia: a systematic review of methodologies

OBJECTIVES

The main objective of this study is to conduct a systematic review to identify and discuss methodological issues surrounding decision modelling for economic evaluation of non-pharmacological interventions (NPIs) in dementia.

METHODS

A systematic search was conducted for publications using decision modelling to investigate the cost-effectiveness of NPIs for individuals with dementia. Search was limited to studies in English. Studies were excluded if they evaluated interventions aimed only at caregivers of patients with dementia, or if they only included economic evaluation alongside an RCT without additional modelling.

RESULTS

Two primary, five secondary and three tertiary prevention intervention studies were identified and reviewed. Five studies utilised Markov models, with others using discrete event, regression-based simulation, and decision tree approaches. A number of challenging methodological issues were identified, including the use of MMSE-score as the main outcome measure, limited number of strategies compared, restricted time horizons, and limited or dated data on dementia onset, progression and mortality. Only one of the three tertiary prevention studies explicitly considered the effectiveness of pharmacological therapies alongside their intervention.

CONCLUSIONS

Economic evaluations of NPIs in dementia should utilise purposefully-developed decision models, and avoid models for evaluation of pharmaceuticals. Broader outcome measures could be a way to capture the wide impact of NPIs for dementia in future decision models. It is also important to account for the effects of pharmacological therapies alongside the NPIs in economic evaluations. Access to more localised and up-to-date data on dementia onset, progression and mortality is a priority for accurate prediction.

The economic burden of dementia in China, 1990-2030: implications for health policy

Objective

To quantify and predict the economic burden of dementia in China for the periods 1990–2010 and 2020–2030, respectively, and discuss the potential implications for national public health policy.

Methods

Using a societal, prevalence-based, gross cost-of-illness approach and data from multiple sources, we estimated or predicted total annual economic costs of dementia in China. We included direct medical costs in outpatient and inpatient settings, direct non-medical costs – e.g. the costs of transportation – and indirect costs due to loss of productivity. We excluded comorbidity-related costs.

Findings

The estimated total annual costs of dementia in China increased from 0.9 billion United States dollars (US$) in 1990 to US$ 47.2 billion in 2010 and were predicted to reach US$ 69.0 billion in 2020 and US$ 114.2 billion in 2030. The costs of informal care accounted for 94.4%, 92.9% and 81.3% of the total estimated costs in 1990, 2000 and 2010, respectively. In China, population ageing and the increasing prevalence of dementia were the main drivers for the increasing predicted costs of dementia between 2010 and 2020, and population ageing was the major factor contributing to the growth of dementia costs between 2020 and 2030.

Conclusion

In China, demographic and epidemiological transitions have driven the growth observed in the economic costs of dementia since the 1990s. If the future costs of dementia are to be reduced, China needs a nationwide dementia action plan to develop an integrated health and social care system and to promote primary and secondary prevention.

Systematic, early identification of dementia and dementia care management are highly appreciated by general physicians in primary care - results within a cluster-randomized-controlled trial (DelpHi)

Background

There is evidence about the benefits of early detection of dementia and subsequent provision of adequate treatment and care. However, there is a lack of knowledge about the acceptance of detection and intervention procedures. These analyses describe the attitudes of general physicians [GPs] toward 1) dementia in general, 2) systematic detection of people with dementia, and 3) an intervention approach after they have experienced both. Comparisons are made based on experience with systematic screening and dementia-specific intervention.

Methods

Postal, cross-sectional survey to all n=1,252 GPs in the Mecklenburg-Western Pomerania, Germany. A subsample was drawn based on participation in the randomized, controlled, prospective intervention DelpHi-MV trial (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania). In this trial, systematic screening is implemented and an intervention group receives support through dementia care management (DCM). GPs were categorized into either GPs with DCM and systematic screening (DCM-GP), GPs with systematic screening only (DelpHi-GP), or GPs not participating in the trial. Data from n=257 GPs were available. Attitudes toward dementia were assessed using a validated questionnaire.

Results

There was strong agreement toward the helpfulness of implementing a brief cognitive screening test (89.9% agreed). Approximately two-thirds of the respondents indicated that they had identified at least some patients as being cognitively impaired for the first time. The majority of the respondents indicated agreement toward DCM. It was described as supportive and helpful. The qualified nurses were perceived as competent in dementia care and 79.3% would like to be supported with DCM. Attitudes toward dementia are positive and do not differ between groups.

Conclusion

The results indicate that early recognition and DCM is highly appreciated by GPs and is considered feasible or wanted to be implemented in routine care.